Thorax, 1977, 32, 501-504 Postoperative lobar torsion and gangrene MICHAEL V. KELLY II, E. ROSS KYGER, AND WARREN C. MILLER From the Departments of Surgery and Medicine, University of Texas Medical School at Houston, Hous!on, Texas 77030, USA Kelly, M. V., Kyger, E. R., and Miller, W. C. (1977). Thorax, 32, 501-504. Postoperative lobar torsion and gangrene. Following left upper lobectomy for a pulmonary nodule, complete 180-degree torsion of the left lower lobe with haemorrhagic infarction occurred. Despite re-exploration within 24 hours of the initial procedure the patient died. Postoperative torsion requires early diagnosis and resection of the gangrenous tissue. Torsion of the lung, or one of its lobes, with the development of gangrene is fortunately a rare event. It has occurred spontaneously in an acces- sory lobe and after chest trauma, hiatal hernior- rhaphy, and resection of pulmonary segments or lobes (Schuler, 1973). We have recently observed such a complication after a left upper lobectomy in a patient with impressively rapid clinical deterioration. Case report A 65-year-old woman with essential hypertension was admitted to hospital because of syncopal episodes associated with antihypertensive therapy. Adjustment of her drug regime eliminated the presenting complaint. However, a routine chest radiograph showed a small density in the left upper lobe (Fig. 1). No previous chest radiographs were available for comparison. Tomography con- firmed the presence of a non-calcified nodule and revealed a smaller adjacent nodule. There was slight fibronodular streaking in the lung and scattered hilar calcification suggestive of previous granulomatous disease. Skin reactivity to inter- mediate strength PPD was negative. Fibreoptic bronchoscopy showed no abnormality. Pulmonary function studies indicated adequate reserve for lobectomy. There were no malignant cells in the sputum, but the lack of calcification and indistinct margins of the mass were suspicious of malig- nancy. During thoracotomy two well-delineated masses were readily palpable deep within the pul- monary parenchyma, precluding wedge resection. Left upper lobectomy was accomplished without difficulty. Histological examination showed multiple granulomata. No organisms were seen. The initial postoperative course was uneventful. A chest radiograph showed good expansion of the left lower lobe (Fig. 2). Vital signs were stable. On 40% inspired oxygen, arterial blood gases were Pao2 187 mmHg (24 9 kPa) and Paco2 38-5 mmHg (5X1 kPa). The next morning moderate hypotension and tachycardia developed but responded favour- ably to fluid therapy. A radiograph showed com- plete opacification of the left chest (Fig. 3). Breath sounds were diminished on the left. The chest tubes were functioning, and there was no air leak or blood loss. A diagnostic thoracentesis failed to obtain fluid. Bronchoscopy revealed the left upper lobe suture line to be intact. The orifice to the left lower lobe was oedematous, distorted, and narrowed. No evidence of aspiration of gastric contents was seen. Despite these marked changes, arterial blood gases on 40% inspired oxygen were Pao2 163 mmHg (21-7 kPa) and Paco2 36-8 mmHg (4 9 kPa). Her clinical condition progressively deteriorated, and so vasopressor drugs were ad- ministered. Because of the suspicion of lobar torsion, she underwent a second exploratory thoracotomy within 24 hours of the first procedure and within 12 hours of the appearance of tachy- cardia. A foul odour was apparent as the incision was re-opened. Complete 180-degree torsion of the left lower lobe was present with occlusion of the bronchovascular bundle at the hilum. The lung tissue was heavy and boggy with a blue-black haemorrhagic appearance (Fig. 4). The lobe was rapidly removed. As the chest was being closed, cardiac arrest occurred. Despite open-chest cardiac massage and drug therapy she could not be resuscitated and was pronounced dead in the operating room. 501 on May 28, 2021 by guest. Protected by copyright. http://thorax.bmj.com/ Thorax: first published as 10.1136/thx.32.4.501 on 1 August 1977. Downloaded from